ACCESS - BT - 2020 10 Airway Update Part 1
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Pre-lecture for the October Block training on Skills.
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ACCESS - BT - 2020 10 Airway Update Part 1
- 1. Halloween Edition⌠ACCESS â BT â 2020 10 Airway Update Part 1
- 2. A couple of Administrative things ⢠In the chat box, Type your First/ Last name and agency # (i.e. Ada #). ⢠If multiple people are watching the same session from the same location, include all. ⢠If On Duty, include your âunitâ, of off duty, note âOff Dutyâ ⢠This is essential to help us issue CE ⢠Example: ⢠Medic 18, Joe Snuffy (611), Beetle Baily (644) and Olive Oil (613)
- 3. Infection Reduction Procedures for this training
- 4. Infection Reduction Procedures for this training ⢠No more than 14-15 participants (3-5 per station with an instructor) with 30-40 feet minimum between stations ⢠Participants will be encouraged not to gather in large groups to chat between stations or after training ⢠All participants and instructors will wear gloves at each station ⢠All participants will wear surgical/cloth masks the entire time at training ⢠All stations will be cleaned as needed between participants ⢠All stations will be thoroughly cleaned between sessions
- 5. Gloves, Gowns, masks, and goggles during the surgical cric station please. Keep those uniforms clean!
- 6. 4 Stations: ⢠âBLS Airwayâ ⢠âBLS-ALS airway Interfaceâ ⢠âAdvanced Airwayâ (ETT and SGA) ⢠âCricothyrotomy Airwayâ
- 9. TWO HANDS FOR FACE MASK SEAL One Hand for BVM Squeeze Remember
- 10. Administration of Oxygen ⢠Reminder: Most cases the SPO2 of 94% is the guiding threshold for O2 administration. ⢠Why? ⢠Constricts coronary arteries! ⢠Constricts cerebral arteries! ⢠Decreased LV output = 11% reduction in systemic oxygen delivery despite increased O2 administration ⢠Is there a good waveform? ⢠Question? Are their exceptions? ⢠Of course. What are they? ⢠Obvious Dyspnea ⢠Obvious shock ⢠Life-threatening Bleeding ⢠Suspected CO or Cyanide toxicity
- 11. NO DESAT (15 + LPM via NC) ⢠NC at âHigh flowsâ for unstable desaturating patients â Protocol: (greater than 6 LPM) â Ideal 15 LPM OR MORE for adults. â Turn the âDead Air Spaceâ into a reservoir â Passive oxygenation ⢠Wash out 21% and irrigate the space with 100%
- 12. If one is goodâŚthree is better⌠â˘Create smooth airflow for easier low pressure BVM
- 13. Nu MASK ⢠BLS Device used interchangeably with BVM mask ⢠Cheap and easy ⢠As reliable as mask with a BVM
- 14. Station 2 BLS â ALS Interface
- 16. Suctioning
- 17. Key Point: KEEP ANYTHING GOING INTO THE TRACHEA AS STERILE AS POSSIBLE Which method would you use?
- 18. Station 3 Supraglottic and Endotracheal Airways
- 19. LMA ⢠Success rates are up again ⢠253 attempts last 12 months (OCT â19-Oct â20) ⢠94% success rate (first attempt)
- 21. LMA Procedure ⢠Key Lessons: ⢠Minimal Inflation (15-35 ml) ⢠Overinflection causes leaks and displacements ⢠Over inflation can compress the carotid arteries
- 22. ETT: Donât forget the Bougie
- 24. New Term: âEmergency front of neck access (eFONA)â ⢠New terminology adopted in anesthesiology in 2017. Covers all types of surgical and needle crics ⢠Emergency front of neck access (eFONA) is the final step in a Can't IntubateâCan't Oxygenate (CICO) scenario. ⢠To be successful: ⢠Train at least yearly ⢠Have a structured plan of when to use these procedures ⢠All members of team must be familiar with process, not just the lead provider ⢠Have kits immediately available at bedside when performing all airway procedures
- 25. Resuscitate BEFORE you intubate ⢠Consider a change From RSI to RAP (Resuscitation Airway Procedures) using the HEAVEN criteria. ⢠H = Hypoxemia/Hypotension ⢠E = Extremes of size ⢠A = Anatomic disruption/obstruction ⢠V = Vomit/blood/fluid ⢠E = Exsanguination ⢠N = Neck mobility
- 26. Have a plan and âBrief team on care plan and contingency actions.â Research shows that a 15 second pre-brief decreases errors and improves team performance.
- 27. The process is simple ⢠Landmarks ⢠Scalpel ⢠Scalpel ⢠Hook (upward) ⢠Bougie (Downward) ⢠Tube ⢠Ventilate
- 28. Keys for success ⢠Stay Midline ⢠Stay Low ⢠Ignore the bleeding until after you get the airway ⢠The Hook pulls up ⢠The Bougie goes down ⢠Secure the tube well
- 29. The end is neigh! ⢠See you at training ⢠Bring your own gloves (at least 2 pair) , googles/face shields, masks, and a gown. ⢠Do not congregate please ⢠Make sure you sign in
Editor's Notes
- Due to COVID, we have taken extra steps to prevent a âsuper=spreaderâ event
- The surgical airway station involves actual pig tracheas and simulated tissue.
- Instruction: This station may be lead by an appropriately trained EMT, AEMT, or Paramedic. Objectives Describe equipment for BLS airway management. Assemble equipment for BLS airway management. Demonstrate proper BVM technique. Demonstrate the proper placement of the Nu Mask in an simulated adult patient.
- Key point: Targets O2 delivery above 94% unless preoxygenating for ETT/RSI
- Simply put, it is a Nasal Cannula used in an atypical way and role to improve oxygenation during airway procedures. So the purpose of NO DESAT is to convert apnea periods into oxygenation periods even though no ventilation is occurring. The easiest way to think of this is not pre-oxygenation, but ongoing oxygenation, even though there may be no respiratory effort. NOTE: The airflow from the nares is superior to the airflow from the oral pharynx, but even this is improved further with anterior displacement of the mandible and good airway positioning. Q: How long can this be done? A: At least 100 min. The difference in oxygen and carbon dioxide movement across the alveolar membrane is due to the significant differences in gas solubility in the blood, as well as the affinity of hemoglobin for oxygen. This causes the net pressure in the alveoli to become slightly subatmospheric, generating a mass flow of gas from pharynx to alveoli. This phenomenon, called apneic oxygenation, permits maintenance of oxygenation without spontaneous or administered ventilations. Under optimal circumstances, a PaO2 can be maintained at greater than 100 mm Hg for up to 100 minutes without a single breath, although the lack of ventilation will eventually cause marked hypercapnia and significant acidosis. Nielsen ND, Kjaergaard B, Koefoed-Nielsen J, et al. Apneic oxygenation combined with extracorporeal arteriovenous carbon dioxide removal provides sufficient gas exchange in experimental lung injury. ASAIO J. 2008;54:401-405 Enghoff H, Holmdahl MH, Risholm L. Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation. Acta Chir Scand. 1952;103:293-301. Holmdahl MH. Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea. Acta Chir Scand Suppl. 1956;212:1-128.. Q: Will it work everytime? A: No, though it will still improve oxygenation over traditional âapneaâ. Those with âShunt Physiologyâ will still require some positive pressure. The exact type (C-PAP, Bi_PAP, NIPPV) will depend on what you have available and situation. Pulmonary shunting is (in simple terms) impaired or altered pulmonary blood flow causing impaired gas exchange. Examples are: Pulmonary Emboli CHF/Pulmonary Edema prohibiting gas exchange Q: What are the uses in EMS? A: Preoxygenation leading up to a âapniec period â (intubation) Possible tool to avoid the CI/CV situation Buy time to better manage the problem Pre-oxygenate during RSI and avoid problems to begin with! Final Point: NO DESAT is just ONE method to provide better oxygenation to the patient. It should be used with multiple approaches NO DESAT effectiveness depends on multiple physiologic factors âPREOXYGENATION EXTENDS THE SAFE APNEA PERIOD. IT SHOULD BE DONE FOR EVERY INTUBATIONâ
- Create smooth airflow for easier low pressure BVM
- Q: Why do we keep the Nu-Mask? A: Because for the BLS companies (UNLIKE ALS RESPONDERS) there are no other options for the BLS provider if they cant make a basic face mask seal. Studies show that the NuMask is as effective in oxygenation and ventilation as a properly sized and applied BVM Mask. It is shown that even with patients with damaged or no teeth, a proper seal can be obtained and maintained. NuMask is a great option for ventilation.
- Instruction: This station may be lead by an appropriately trained Paramedic. Objectives Demonstrate proper suction of an advanced airway in an simulated adult patient. Demonstrate proper suction of a tracheostomy tube in an simulated adult patient. Describe proper use (indications, contraindications, dosage) for CPAP in a simulated adult patient. Demonstrate placement of CPAP in a simulated adult patient.
- Trach suction and advanced airway is an optional module for EMTs and a core skill for AEMTs and Paramedics. This is an example of an adult trach. A pediatric trach is single cannula only due to its smaller size.
- Many reasons or times to suction: - Any time the patient feels or hears mucus rattling in the tube or airway - In the morning when the patient first wakes up - Before meals - Before going outdoors - Before going to sleep We will focus on 1: When there is an increased respiratory rate (working hard to breathe). Infection is always a HIGH consideration in suctioning the tracheostomy. You are inserting a catheter into the trachea and close to the Corina. Introducing bacteria will increase likelihood of infection, so cleanliness is needed for this procedure and maintaining a sterile catheter is essential.
- Discussion point: Compare and Contrast the in line suctioning and the single use suction cath. Pass the demonstration models around. Note; In the field we cant be âsterileâ but we can be âasepticâ. If the patient has a sterile tray, do not be afraid to use it.
- Objectives Demonstrate proper oral tracheal placement of an endotracheal tube in a simulated adult patient. Demonstrate proper placement of a supraglottic airway (LMA Supreme) in an simulated adult patient. (EMT/AEMT providers) Assist in the placement of an advanced airway in an simulated adult patient.
- Stats according to ESO Oct 19-Oct 20 Remember, moist airways are most complicated. Suction as needed, secure airway before inflation, use care with insertion that you donât damage balloon, donât over-inflate.
- Go over the anatomy of the LMA
- Emphasize the use of the Bougie whenever possible, not just when a difficult airway is anticipated or when an attempt fails. It can be used on the first attempt.
- Objectives Demonstrate proper performance of a surgical cricothyrotomy in a simulated adult patient. Demonstrate proper performance of a percutaneous (needle) cricothyrotomy in an simulated adult patient. (EMT/AEMT providers) Assist in the placement of a cricothyrotomy in an simulated adult patient.
- Emergency front of neck access (eFONA) can be defined as the securing of a patent airway via the anterior neck to facilitate emergency alveolar oxygenation. eFONA is the final lifesaving step in airway management to reverse hypoxia and prevent resulting brain injury, cardiac arrest, and death
- H = HypoxemiaâGood BLS airway maneuvers are key. We tend to forget how important airway adjuncts are. If patients can take one NPA, they can take two. If they can take an OPA, they can take an NPA. Using these adjuncts helps provide more flow when we ventilate. Donât forget about patient positioning! E = Extremes of sizeâDoes the patient need to be ramped? Elevate the head of the bed so gravity doesn't work against you. Which equipment do you use, video or direct? What blade choice? A = Anatomic disruption/obstructionâWhat do you notice from your assessment? Has there been blunt or penetrating trauma? Previous intubations or surgeries with scar tissue? Radiation or tumors? Have a plan to mitigate these factors prior to pushing induction agents or paralytics. V = Vomit/blood/fluidâEmploy SALAD (suction-aided laryngoscopy and decontamination). Have the right equipment on hand (such as a DuCanto suction catheter) and make sure it functions appropriately prior to use. E = ExsanguinationâDo we need to control bleeding? Fluid-resuscitate? Increase blood pressure before giving medications that take away compensatory measures? Literature suggests the combination of a low EtC02 (less than 24 mmHg) and systolic BP of less than 80 mmHg means CPR will be needed within eight minutes. N = Neck mobilityâDo you need to keep c-spine in line, or is there room for manipulation? Will being inline restrict your view, requiring a modified technique?Â
- This is an example of a simple, direct difficult airway procedure. Emphasize the 15 second crew brief.
- Stay low, Stay midline, Ignore the bleeding to secure the airway.